Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]

Facility

$0.89

Service Code	HCPCS S0090
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.84
Rate for Payer: Aetna of CA Government/Medicare	$0.84
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cash Price	$0.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Commercial	$1.05
Rate for Payer: Multiplan Commercial	$0.67

SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]

Facility

$0.69

Service Code	NDC 8019629660
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]

Facility

$0.69

Service Code	NDC 8327030909
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]

Facility

$0.69

Service Code	NDC 8327030909
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]

Facility

$0.69

Service Code	NDC 8019629660
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]

Facility

$0.91

Service Code	NDC 12870-0001-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.73
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]

Facility

$0.91

Service Code	NDC 12870-0001-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.55
Rate for Payer: Aetna of CA Government/Medicare	$0.55
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]

Facility

$0.84

Service Code	NDC 12870-0001-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.63

SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]

Facility

$0.84

Service Code	NDC 12870-0001-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.63

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.54

Service Code	NDC 67877-124-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.31

Service Code	NDC 61570-131-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.30

Service Code	NDC 43598-210-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.36

Service Code	NDC 43598-210-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.36

Service Code	NDC 59762-0131-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.29

Service Code	NDC 59762-0131-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.30

Service Code	NDC 43598-210-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.36

Service Code	NDC 59762-0131-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.31

Service Code	NDC 61570-131-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.41

Service Code	NDC 67877-124-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.31

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.36

Service Code	NDC 43598-210-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.41

Service Code	NDC 67877-124-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.31

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.29

Service Code	NDC 59762-0131-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.29

Service Code	NDC 59762-0131-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.29

Service Code	NDC 59762-0131-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$0.54

Service Code	NDC 67877-124-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

Know your out-of-pocket cost for care.

All Charges